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! <br /> � <br /> ; <br /> I <br /> i <br /> Contractor Section: . ! <br /> � <br /> /� �._ - � `' ' �_��t.���� L�.G /r�C%� ;�.� � <br /> �-1'�i� : ' , . <br /> Vendor Name/ Busine s Name/UBI Number ! <br /> � �t6� I IC � + <br /> �.��i.Z•�-� � <br /> St2te of Washington Contractor License Number. ! <br /> i <br /> ��,•�[U Lr�r_._�i�1_��,.-.��1_��'1-f' <br /> L�(.�Cd ���G� I <br /> Vendor Mailing Address City Slate ZiP <br /> /� / i <br /> � -;Jf7l�••�(7��1 �%�i'_iC�tl 1_C.aL�_c'�,���_._��S1rlQ�-C=r'ii'� _ i <br /> Phone Email s <br /> i <br /> ; <br /> � <br /> I,lhe Vendor, agree to receive the Backwater Prevention DevicF. rebate check direclly for Ihe ; <br /> ins;allalion at lhe above referenced properly address. By agreeiny io receive the rebate check j <br /> directly, I agree to the foliowing: � <br /> 1. The Backwater Prevention Device rebale amount will be deducted from the final invoice � <br /> given to tho property owner for the installalion at the propeity address referenced above, if � <br /> the tolal cost of the installalion is greater lhan Ihe rebale. � <br /> 2. I,the Vendor, am a Washington State licensed contrector. � <br /> 3. The City of Everelt will send a Pederal Form 1099 MISC to me, the Vendor, for Backwater f <br /> Prevenlion Device rebate payments lotaling more than $600 per calendar year, and wiil � <br /> report lhe same payments to ihe Internal Revenue Service. � <br /> I <br /> — ---— — { <br /> — , <br /> I accepl the paymenl of lhe f3ackwater Prevention Device rebate from lhe City of Everett pending ` <br /> approval of the eompleted Bacicwater Prevention Device rebate package by the Ciry ot Everett ; <br /> i <br /> � <br /> � � <br /> ��.�- �7� _ a . - r,�-- ; <br /> Signature o(Contraclor Date � <br /> � <br /> � <br /> ——--- ---- — — ---- j <br /> f <br /> � <br /> � <br /> � <br /> I <br /> I <br /> f <br /> I <br />